“Lost to follow up” is a too-common refrain in the ambulatory healthcare setting and is particularly problematic in primary care, whose focus and value lie in an ongoing, longitudinal relationship with the patient. Academic primary care practices often care for socially or medically complex patients and may lose 25-45% of patients to follow-up. Patients, PCP teams, and the system are all impacted differently by this challenge. Patients can experience a decline in their health status and poor outcomes if they cannot access care in ways and at times that are convenient for them.

Permanent vision loss is prevalent among the aging and will continue to rise. There are gaps and barriers resulting from fragmented care locally and globally. The health inequity among the aging, visually impaired population is also a public health issue with an economic burden on state and federal resources. The CDC reports that 4.5M over age 40 report that they are blind. This number is expected double to 9M by 2050. There are 21M more who reports having “vision problems” not correctable with conventional glasses, contact lenses, or refractive laser surgery.

We face an escalating addiction epidemic, with more than 100,000 people dying of drug-related overdoses in the US in 2021—the highest number of deaths ever recorded. San Francisco has the highest overdose death rate in California. At SFGH, more than 1/3 of hospitalized patients have a substance use disorder (SUD). Our patients with SUD have longer lengths of stay (3 v 5 days), 1.5x higher 30-day readmission rates, and 5x higher self-discharges than those without SUD.

Patients with Mental Health (MH) conditions have poorer quality outcomes and experience persistent barriers in accessing care than those without MH conditions. Individuals with a Serious Mental Illness (SMI) or Substance Use Disorder (SUD) die over 20 years earlier than individuals without such a diagnosis. People with MH diagnoses incur costs more than those without MH disease. While the current health delivery system is shifting, it often separates Physical and Mental Health care.

As indicated in the subtext of my CHIP title, I’m sharing a mix of project and leadership journeys. Especially in the pandemic era, it seems (at least for me), the threads of personal and professional experience are increasingly intertwined. For my CHIP, I started with the question of: How might we develop and implement a respectful, comprehensive, and trauma-informed model of care for pregnant and parenting people that better coordinates existing medical, behavioral health and social services and creates continuity across the birth divide?

People returning from incarceration face a myriad of health inequities, including increased emergency department utilization, hospitalization and death. In the first 2 weeks post release, people are 12 times more likely to die than their community counterparts from health conditions that could be treated in the primary care setting (including SUD, cardiovascular disease, mental illness and cancer).

I wanted to design a care model that was focused on delivering on the needs of clinicians as a primary intention. Too often I’ve found that in order to meet the patient needs sacrifices and compromises are made regarding the needs of clinicians in clinical program design. The common thinking is that it’s incumbent on clinicians to sacrifice for the sake of their patients. Instead, we interviewed clinicians on what were there most pressing needs and build our clinical care delivery program with those insights.

Telehealth has always interested me as a model of care to decrease barriers and increase access to care, but prior to the pandemic state of emergency there wasn’t a reimbursement model for FQHCs in primary care. We were doing some telehealth with remote specialists, bringing patients to the clinic for visits, but nothing in primary care or with remote patients. Then everything changed. Over 2 weeks in March 2020, we went from 100% in-person visits, to only 15%, the remaining 85% remote telehealth.

Marginalized communities were disproportionately affected by the COVID-19 pandemic with increased cases, hospitalizations, and deaths. As the County COVID-19 testing lead, I worked to ensure equitable access to COVID-19 testing in marginalized communities across Los Angeles County.

The CHIP was a focal point of the CHCF program, but my true CHIP came through learning about myself as a leader during challenging times. Fueled by burning questions and supported by mentors, friends and family, I managed to thrive during the past two years. Given all the crises in the world, and given my personal and professional investment in mental health, what could I do to contribute? How might we improve our communities’ health and wellbeing?